EXECUTIVE SUMMARY

Case managers can help improve healthcare access for transgender patients through proactive steps, including learning more about the terminology related to transgender identity.

  • Case managers also should focus on social determinants of health, helping transgender patients find providers and community resources that work with this population.
  • One of the most important things a case manager can do is respect transgender patients by using the names and pronouns they prefer.
  • Screen for mental health illness as transgender individuals are affected by depression and suicidal ideation at greater rates than the general population.

The first thing case managers should do to improve care of transgender patients is to know the terminology and framework involving a transgender individual.

“They go through surgeries and hormone treatment, so understand the words they use; understand prejudice, discrimination, and the negative reactions with the healthcare system and criminal justice system,” says Michael Garrett, MS, CCM, principal at Mercer in Seattle.

Patient care of transgender individuals is like general patient care in which the case manager focuses on the medical and patient goals, says Carl Streed, Jr., MD, MPH, FACP, an assistant professor of medicine, section of general internal medicine, at Boston University School of Medicine, and research lead, Center for Transgender Medicine and Surgery, at Boston Medical Center. “It’s not always related to the goals of their trans identity,” Streed says.

Streed and Garrett offer these suggestions for best practices in care of transgender patients:

• Understand the language. Pay attention to pronouns when addressing or discussing transgender patients and their spouses, Garrett suggests.

“Ask about the person’s spouse, as opposed to saying ‘husband’ or ‘wife,’” Streed says. “Say ‘siblings,’ not ‘sister/brother.’”

Healthcare providers should understand how to communicate with transgender patients. They also need to know terminology related to the treatment and surgeries they might need, Garrett says.

Case managers also should know what “nonbinary” means. A patient who identifies as nonbinary is someone who identifies as having no gender or gender identity. Nonbinary patients might ask that you refer to them as “they,” instead of he or she, and “them,” instead of him or her.

“In the flow of conversation with the individual, ask what pronoun they use, and case managers can say which pronouns they use,” Garrett says. For example, Garrett lists in emails his preferred pronouns: “Pronoun: he/his/him.” Streed also lists his preferred pronouns in emails: “Pronouns: he, him, his, himself.”

• Focus on social determinants of health and medication needs. “Make sure they have access to safe housing, food, and transportation,” Streed says. “Specific to the trans population, it’s also important that they have access to their medication that affirms their gender identity.”

Case managers can help their transgender patients find physicians who provide hormone therapy. They also can help patients deal with insurance companies and their exclusions that might make it difficult for some transgender patients to receive the treatment they need, Streed says.

For instance, the Affordable Care Act includes a provision that protects transgender people from discrimination in healthcare and insurance coverage. (More information is available at: https://bit.ly/358KVTN.)

“There still is discrimination in healthcare policies,” Streed notes. “Whenever there’s an exclusion or someone saying they won’t provide estrogen for a patient while a government document still says the person is male, then you need to talk with insurance companies.”

• Be cognizant of mental health needs. Streed offers transgender patients a mental health evaluation because so many people in this population have experienced trauma and discrimination.

Nearly half of all transgender adults say they have considered suicide within the past 12 months. By contrast, only 4% of the overall U.S. population has reported they have considered suicide in the past year, according to the National Alliance on Mental Illness. (More data are available at: https://bit.ly/2dX9rwi.)

• Respect transgender patients’ identities. There are many examples of transgender patients not being treated with respect for their identity, Garrett says.

“Healthcare providers sometimes are not willing to identify the individual by the gender they identify with,” he says. “Some are not willing to accept them as patients.”

In Garrett’s paper on case management and transgender patients, he told the story of a 45-year-old woman who entered a clinic for the first time. She told the receptionist that she was there for a full evaluation and her name was Brenda, although her identification listed Brian. She had not yet changed her ID. But the nurse called for ‘Brian’ instead of ‘Brenda,’ resulting in Brenda’s embarrassment as some other patients and staff laughed. The nurse case manager confirmed Brenda’s preferred pronoun and apologized for the mistake, saying she would discuss this with the staff.1

“Educate yourself,” Garrett suggests. “Understand the framework, language, and what it is to be a transgender male and female and what ‘transition’ means.”

• Understand specific health needs. One issue that can arise with transgender patients is the effect of their hormonal treatment on other health conditions. For example, there is a cancer that is sensitive to sex hormones. A patient with this disease might have to make a difficult choice of whether to continue with the hormones that allow the person to be who they want to be, or to discontinue the hormones for their health, Streed says.

“If a patient has a cancer with a hormone sensor, we’d have a serious conversation,” he says.

There also is some concern that some hormone treatment can lead to higher blood pressure and put people at a greater risk of heart attack or stroke, but the science is lacking, Streed says. “For women, estrogens can increase the risk of clotting,” he adds.

REFERENCE

  1. Garrett MB. Working with transgender individuals in case management practice. Prof Case Manag 2018;23:19-24.